January 25, 2022
by Dr. Vi Thuy Nguyen
Dr. Sara Valladolid and I completed our AAP CATCH Grant Proposal on “Rewild the Child to Counter ACES.” We are including relevant parts of the proposal here so it is available to our colleagues, partners and the public. We believe that wetland restoration and rewilding work can heal not only the earth, but pediatricians and children who suffer a higher burden of asthma and adverse childhood events. Crossing our fingers that our idea and dreams win the grant. But the most important thing was writing this grant focused our minds and our hearts. It’s no an option. We have to do these kinds of projects. It’s for our shared children, community and planet. Let’s get this done.
What personal experience led you to become interested in community pediatrics or choose this child health topic for a CATCH project?
Serendipity. My simple story is that about two years ago in the midst of being Assistant Chief of Pediatrics, practicing general pediatrics and being a mom and wife – I became completely burned out. I’ve shared my story of the blogsphere so I won’t rehash it here but it’s all on a KevinMD podcast if you want to hear. But I began jogging to the beach and started plogging, and I found happiness and quiet and renewal. I’m now trying to get to 1000 bags of trash (I’m on bag 610 now!) and along the way I’m trying to do everything I can to stop this existential crisis of climate change by literally cleaning the earth. Picking up trash and the time on the beach has taught me how interrelated we all are, and has taught me to look around and know the answer is often right in front of us. This particular project is
inspired that my best friend at work is also Dr. Sara Valladolid who is our ACES lead and the lead of our Child Abuse Team, and we often talk about how do we solve the triple threats of ACES, climate change and physician burnout. I’m active in rewilding political efforts of Mission Bay, and it makes sense to me that the answer to addressing ACES is getting kids outside in natural spaces with caring pediatricians/health care providers. It makes sense to me that we can restore the earth and restore ourselves together in these natural spaces.
Please provide a full summary of your project.
ACES is a determinant to health. Traumatic events when children are mentally or physically challenged induce an adrenaline response. Over prolonged exposure this causes physiologic changes which increase the risks of cardiac disease, cancer and high blood pressure. Children will have increase rates of depression, suicidality and substance abuse. Pediatricians try to advocate for children, providing information to families about the dangers of ACE’s and positive events in childhood that can build resilience. These children need a greater sense of wellbeing and stability.
We also have the existential crisis of climate change. Climate change is a public health crisis, and more importantly to pediatricians – it is a pediatric public health crisis. Over 88% of the diseases caused by climate change affect children under five years of age. Children are uniquely at risk to air pollution and heat. Climate change is accelerated because natural places that should provide spaces to heal like wetlands are being continually threatened, and their ability to sequester carbon and provide habitat for all life is reduced.
Setting: Wetlands at Kendall Frost Reserve and National Wildlife Refuge, San Diego Audubon Society
Persons Affected: 61% of adults report at least one type of ACE. 1 in 6 report they had experienced four or more. Racial minority groups are at greater risk for having multiple ACEs. These same groups often live in Environmental Justice neighborhoods. Children with >4 reported ACES have 4x the rates of asthma, and often live in neighborhoods with higher particulate air pollution.
Goal: To develop a no-cost to participants, low-cost to society, and high-yield to the earth program that will enable pediatricians and child mental health providers to effectively prescribe Rewilding events like Rewild Mission Bay “Love Your Wetlands Day” to children with multiple ACES. Particular emphasis on children with multiple ACES and asthma.
Intervention: Wetlands are vital to combating climate change. Wetlands are one of the best carbon sinks on the planet and store 5x more carbon per equivalent area than tropical forests. Studies have shown that “blue spaces” including coastal, river and other freshwater ecosystems and “green spaces” have important mental and physical health benefits for humans. Wetlands uniquely provide both blue and green spaces. We also acknowledge the importance of being outside, exploring and imagination in improved wellbeing for children particularly for those with multiple ACES. Yet these children are often those from EJ communities who have the least access to blue and green spaces and access to caring adults who can provide these positive childhood experiences.
We will develop an ACES intervention “Rewild the Child to Counter Aces” within the space of the wetlands at Mission Bay and the National Wildlife Refuge with the San Diego Audubon Society. We will develop a curriculum that allows children to be in natural spaces with their health care providers, and do activities
that quiet their mind, move their bodies like land restoration, picking up plastic, removing invasive and replanting native species. Children will take “earth vital signs” like PM2.5 levels with air pollution monitors and also take their own “human vital signs” – pulse ox, heart rate, and stress levels and see how these are related. It would be cognitive behavioral therapy in the field!
Anticipated Outcomes: Pediatricians will find a greater sense of connectivity and meaning in their work outside of the walls of the clinic. The children will have positive experiences. Wetland conservationist will benefit from public awareness about the importance of wetlands to sequester carbon and restore health. The hopeful outcome would be to bring joy and healing and change the national conversation on how we address these issues.
Please describe the community where your project will be located.
We envision this project will be primarily for urban children initially in the areas of San Ysidro, Otay Mesa, west Chula Vista and National City area and their pediatricians. San Diego Audubon Society helps manage the wetlands at the Kendall Frost Reserve and the South Bay National Wildlife Refuge that are relatively accessible by public transportation and easy driving distance for urban families. These neighborhoods are primarily urban neighborhoods with higher burden of poverty, unemployment and linguistic isolation. For example according to the California EPA CalEnviro Screen, the Otay Mesa region 62 percent of people in this census tract are living below twice the federal poverty level. The percentile for this census tract is 93, meaning the percent of people living below twice the poverty level is higher
than 93% of the census tracts in California. For west Chula Vista, there is a high burden of linguistic isolation. 18 percent of households in this census tract do not speak English well. The percentile for this census tract is 82, meaning the percent of linguistically isolated households is higher than 82% of the census tracts in California. For adult household unemployment the San Ysidro and Otay Mesa region 11 percent of adults in the census tract are unemployed. The percentile for this census tract is 89, meaning the percent of unemployed people is higher than 89% of the census tracts in California. We forsee starting with local pediatricians who practice around that area concentrating initially who are part of the AAP San Diego, about 40 in total with small groups of their own patients who want to participate .
Please describe the target population.
Target population are children who live in the EJ neighborhoods of San Ysidro, National City, Otay Mesa and west Chula Vista. Racial minorities who share a higher burden of asthma and air pollution, less tree/green space equity and a higher burden of ACES will be prioritized. There are stark health disparities for chronic medical conditions. The burden of pediatric asthma is four times greater in these neighborhoods. This is directly related to particulate matter exposure and in the San Ysidro and Otay Mesa region the most recent CalEnviro index indicates that this census tract has a concentration of 12.82 micrograms per meter cubed (12.82 µg/m3). The PM2.5 percentile for this census tract is 93, meaning it is higher than 93% of the census tracts in California. These neighborhoods being predominantly minority also are known to have a higher burden of adverse childhood events on screening surveys, and less access to mental health services. Many activities that would naturally expose children to wetlands/green spaces and the mental health benefits require extensive family and community resources that are less available to these children. For example, the well established programs of Girl Scouts and Boy Scouts require parental time, volunteer efforts and financial support that are out of reach for many families. Despite Girl Scout and Boy Scout’s efforts to be more available in EJ neighborhoods and recent national outreach to Hispanic and other minority groups, there remain barriers. Yet most children do have a pediatrician that can act as a bridge to these experiences. Outreach will be to pediatricians and their
patient’s who practice in these areas and serve a primarily low-income population, and special emphasis will be given to outreach to pediatric patients with asthma that screen for multiple ACES. By addressing toxic stress, we will benefit mental and respiratory health.
BARRIERS & ACCESS
For children who have more ACES from EJ neighborhoods, there are multiple barriers to access the restorative experience of Rewilding and Nature Experiences that emphasis the building of resilience. San Ysidro, Otay Mesa, National City and west Chula Vista are neighbrhoods that include geographic, socioeconomic and communication barriers to access these programs. A majority of children who live in these areas have higher burden of linguistic isolation, transportation challenges to access wetlands, and also the real barrier to venturing into coastal neighborhoods that technically belong to all children but culturally feel like out of reach enclaves that do not include them. There is also lack of family and provider knowledge about how to easily access Rewilding efforts and nature based activities to address mental health challenges for children. There is a lack of perceived time and organization and workflow barriers within healthcare systems that are challenged with a disproportionately high rate of children experiencing ACES. The answer that most health care systems have made is patient education materials, limited social service referrals and outpatient psychiatry referrals. The truth is that most people don’t have the time or inspiration to read more patient education material, and social services referrals fall through the cracks, and there are not enough mental health providers in the country to adequatel address ACES is the current health care model.
Our planning grant seeks to create a curriculum where general pediatricians can act as a bridge and trusted messenger regarding the health benefits of rewilding, and a conduit to build community bonds and trust between our patients who need wetlands the most and the organizations like UCSD Natural Reserve System and the San Diego Audubon Society that want to play a healing role for the earth and also for our children’s mental health. The perceived barrier is mostly trust. Children who most need these spaces and programs are from families that often lack trust that these natural spaces belong to them as well, and lack trust in programs staffed by adults from institutions and communities that seem foreign. But most families trust their pediatrician. A child with moderate asthma who suffers from multiple ACES living in an urban EJ neighborhood with working-class parents, will unlikely be able to enroll in a rewilding/nature based program led by outside groups. Yet this same child usually is able to make it to a clinic visit, brought by a caring adult in their family. Instead of the clinic, why don’t we rethink the practice of medicine and child mental health and meet at the wetlands. Meet your pediatrician and their wetland conservation friends, and let’s reset what it means to be well for everyone – for the earth, for the child and also for the pediatrician. I have done this with my patients on a volunteer basis, cleaning the beaches together and in the natural light of the real world. And I can tell you fleeting moments of being together and practicing mindfullness and land restoration activities are powerful. These are moments where you can model behaviors, and develop real sense of connection. But other pediatricians are not as
brave as I have been, and likely worry in this real world regarding feasiblity, liability, curriculum and outreach to their patients. This program seeks to remove those barriers. Let us figure out the barriers, so that we can come together in these natural spaces to address the toxic stress of ACES.
Describe how your project will assess children’s health or well-being and/or increase access to needed health services not otherwise available.
“Rewild the Child to counter ACES” will bring together pediaticians who are working on ACES, environmental organizations like the San Diego Audubon society, and families that would most benefit from these type of experiences. Most children have an identified pediatrician or medical home, and this medical home already is tasked to identify children with ACES. We seek to help pediatricians be able to “prescribe nature” in regular events organized by wetland conversvation areas like Rewild Mission Bay/San Diego Audubon, and pair these events with children assessing their own “vital signs” and also “earth vital signs.” The program would explore using easy scoring systems like “Well-being Indicator Tool for Youth” [WIY-T] as a way to help children, parents and pediatricians link nature-based activities and land restoration activities with improved mental and physical health.
We believe our program is unique in that it will demonstrate to families, pediatricians and the general public the interrelatedness of simple restorative activities in nature that can address ACES and pediatric asthma. It has been shown that childhood adversity is associated with higher rates of asthma, and worsening asthma severity. Restorative programs in nature spaces that emphasize mindfulness and wellness, will address the toxic stress and dysregulated coritsol response that affect these children. Wetlands also are areas with relatively less particulate air pollution, and will bring awareness to children with asthma the relatedness of their disease processes with their environment.
List your current community collaborative partners and describe their role in your project.
We will be working through the AAP-CA3 San Diego Climate Change and Health Committee. Our primarily role will be to bring all interested groups together and develop the curriculum, goals, rubrics and initial events. We would work to make this sustainable and look for funding within health care organizations (possibly Sharp and Kaiser). Our job will be to get this project done, so that we can further the national conversation that Rewilding Efforts and Nature Based activities are part of the answer to Child Mental Health and can be a “prescription” to adverse childhood events.
San Diego Audubon Society and Conservation Managers Andrew Meyer and Megan Flaherty will provide leadership from the wetland community. Also Audubon educators have a problem geared to children called “Sharing our Shores” that does not have a mental health component to it yet, nor a climate and health component. We will provide networking with other organizations that are exploring kayak/paddle boarding experience at the northeast corner of the Marsh.
UCSD Natural Reserve System – Kendall Marsh Reserve technially owned by UCSD Natural Reserve System
Kaiser San Diego Pediatrics – collaboration with Drs. Pamela Villar and Sara Valladolid who are working on a mindfulness clinic for children with high burden of ACES, and they are exploring incorporating a naturebased component ot this clinic.
San Diego Pediatric Leadership Council – In general we are both well connected with the region’s pediatric leadership including the leadership council and within the AAP. We believe we can leverage our current leadership positions to influence and find acceptance for this type of program across medical groups in San Diego. This helps everyone and helps the earth
Describe project-related activities that have been completed to date. Also include those activities that are anticipated to be completed prior to the project start date.
Partnerships are now established between the AAP San Diego Climate Change and Health Committee, San Diego Audubon Society (Rewild Mission Bay), UCSD Kendall Frost Natural Reserve System and local pediatricians who are working on ACES (screening for adverse childhood events). Larger regional and national support has already been established within Kaiser San Diego, local physicians who are part of climate and health advocacy, and the National AAP Climate Advocate program. We have started discussion with the AAP Orange County Climate Change and Health Committee and Boca Chica Ecological Reserve, to consider replicating this in OC if we get this off the ground. We are colleagues with Kaiser Orange County pediatric department that could replciate this within Kaiser.
We have identified engaged team members from each organization. We know there is interest within youth groups. We have written about the health benefits of wetland restoration including the mental health benefits in a blogpost nationally published by Climate for Health/ Eco-America entitled “Saving Our Wetlands A Climate Solution to Improve Community Health” authored by Dr. Ben Schleifer, https://climateforhealth.org/saving-our-wetlands-a-climate-solution-to-improve-community-health/. A similar article has been accepted in proposal form by Ciencia Cakotanú Magazine, a popular science magazine published in Yucatan Mexico. Luis Herbert, editor-in-chief, is interested in our idea. Their group has a Turtle rescue camp in Yucatan. We believe our efforts are similar and we can amplify each other. We already have facebook/web/instagram presence.
AAP San Diego has officially joined the Rewild Mission Bay coalition. I am already part of the planning committee for “Love Your Wetlands” day which will be February 5, 2022. We have a table where we are going to raise public awareness regarding the mental health benefits of wetland restoration and offering two upcycled art projects.
What will be your responsibilities in carrying out the project?
I will be the primary person to bring the partners together, and dialog between the different health care organizations within San Diego and the wetlands conservation community.
(1) I will work to identify and secure funding for sustainability.
(2) I will attend all the meetings. possible
(3) I will network within the San Diego healthcare system to coorinate efforts within Kaiser, Sharp and AAP. I believe my position as a pediatric departmental leader and within the state enables me to do this more easily. I can also do this through the San Diego Pediatric Leadership Council, which I am a member.
(4) I will write at least at least two written pieces to spread this idea, including the previously mentioned article in the Yucatan science magazine, submit an academic/advocacy piece to the Journal of Climate Health, and also present this work at AAP California NCE and Kaiser pediatric symposium. I am also active on climate and health groups, like the Physicians for Sustainable Future Facebook group and will spread this idea.
(5) I will identify premedical student that can assist in this work, and through already established
mentoring program through the AAP San Diego – will mentor two students to assist in this work as part of
their professional development.
(6) I will report back to the National AAP Climate Advocate program regarding success and failures, so that this will truly be a national dialog.
(7) If this works, I will try to spread this nationally especially within the Kaiser system which includes California, Oregon, Washington, Hawaii, Mid Atlantic and Georgia. If I have AAP support, than I can more easily justify within my own healthcare system and others that this as a community is part of the answer to the dual crisis of childhood ACES and the climate change.
How will you measure the achievement of your SMART objectives and project goal (such as completion of a community assessment, coalition formed, community forum held, number of grants submitted, number of committee or task force meetings, number of surveys, focus groups, or interviews)?
(1) Completion of program curriculum with agreement between coalition members (AAP, San Diego Audubon Society, UCSD)
(2) Needs Assessment within referral health care organizations (Kaiser, Sharp, ect) for number of children who could be referred who meet criteria, and patient capacity within the coalition in terms of number of patients per year to participate.
(3) Referral workflows completed with input from local pediatric health care groups, and can work through the AAP and the San Diego Pediatric Leadership Council
(4) One year (4-6 sesssions total) pilot sessions scheduled for “Rewild the Child to COUNTER ACES”
(5) Two long-term grants submitted to San Diego Foundation, Kaiser Community Benefits and Sharp Community Benefits.
